Evidence map›Paper›PMID 28666439›Full record

ArticleBMC health services research2017

Preventing blood transfusion failures: FMEA, an effective assessment method.

Zhila Najafpour, Mojtaba Hasoumi, Faranak Behzadi, Efat Mohamadi, Mohamadreza Jafary, Morteza Saeedi

Abstract read
In one paragraph

Article in BMC health services research, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 11 papers.

0numbers the graph read from it
0cells of the map it votes in
11citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

11 citing papers in PubMed.

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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

6 authors.

Zhila NajafpourHealth Care Management, Department of Health Economics and Management, School of Public Health, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Mojtaba HasoumiHealth Economics, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
Faranak BehzadiHealth Policy, Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
Efat MohamadiHealth Policy, Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
Mohamadreza JafaryShariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. mrezajafary@yahoo.com.
Morteza SaeediEmergency Medicine research center, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundFailure Mode and Effect Analysis (FMEA) is a method used to assess the risk of failures and harms to patients during the medical process and to identify the associated clinical issues. The aim of this study was to conduct an assessment of blood transfusion process in a teaching general hospital, using FMEA as the method.

methodsA structured FMEA was recruited in our study performed in 2014, and corrective actions were implemented and re-evaluated after 6 months. Sixteen 2-h sessions were held to perform FMEA in the blood transfusion process, including five steps: establishing the context, selecting team members, analysis of the processes, hazard analysis, and developing a risk reduction protocol for blood transfusion.

resultsFailure modes with the highest risk priority numbers (RPNs) were identified. The overall RPN scores ranged from 5 to 100 among which, four failure modes were associated with RPNs over 75. The data analysis indicated that failures with the highest RPNs were: labelling (RPN: 100), transfusion of blood or the component (RPN: 100), patient identification (RPN: 80) and sampling (RPN: 75).

conclusionThe results demonstrated that mis-transfusion of blood or blood component is the most important error, which can lead to serious morbidity or mortality. Provision of training to the personnel on blood transfusion, knowledge raising on hazards and appropriate preventative measures, as well as developing standard safety guidelines are essential, and must be implemented during all steps of blood and blood component transfusion.

Indexed as

Blood TransfusionHealthcare Failure Mode and Effect AnalysisHumansMedical ErrorsRisk ManagementTransfusion ReactionTreatment FailureBlood transfusionFailure modesFMEARisk analysis

Identifiers

PMID28666439
PMCPMC5493120

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.